Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections

Rinse, gel, and foam - is there any evidence for a difference in their effectiveness in preventing infections?

BACKGROUND

Following publication of the 2009 World Health Organizations Guidelines for Hand Hygiene in Health Care, a debate has emerged regarding the relative antimicrobial efficacy of the different formats (rinse, gel, foam) of ABHRs and their ability to contribute to reduction of healthcare-associated infections (HAIs).

METHODS

Data regarding the in-vivo antimicrobial efficacy of ABHRs and other factors that likely affect their effectiveness in reducing HAIs were reviewed, and a comprehensive review of studies that reported the effectiveness of each of the three ABHR formats to improve hand hygiene compliance and reduce HAIs was conducted.

RESULTS

The amount of rubbing time it takes for hands to feel dry (dry time) is the major driver of ABHR antimicrobial efficacy. ABHR format is not a major factor, and several studies found that rinse, gel, and foam ABHRs have comparable in-vivo antimicrobial efficacy. Other factors that likely impact the ability of ABHRs to reduce transmission of healthcare-associated pathogens and HAIs include ABHR formulation, the volume applied to hands, aesthetic characteristics, skin tolerance, acceptance by healthcare personnel, and hand hygiene compliance rates. When accompanied by complementary strategies, promoting the use of each of the three ABHR formats has been associated with improvements in hand hygiene compliance rates. A review of 67 studies failed to identify an ABHR format that was significantly more effective in yielding statistically significant reductions in transmission of healthcare-associated pathogens or HAIs.

CONCLUSIONS

Current evidence is insufficient to definitively determine if one ABHR format is more effective in reducing transmission of healthcare-associated pathogens and HAIs. More rigorous studies such as multicenter randomized controlled trials comparing the different formats are needed to establish if one format is significantly more effective in reducing HAIs.

Ten years of hand hygiene excellence: a summary of outcomes, and a comparison of indicators, from award-winning hospitals worldwide

BACKGROUND

Hand hygiene is a crucial measure for the prevention of healthcare-associated infections (HAIs). The Hand Hygiene Excellence Award (HHEA) is an international programme acknowledging healthcare facilities for their leadership in implementing hand hygiene improvement programmes, including the World Health Organisation's Multimodal Improvement Strategy. This study aimed at summarising the results of the HHEA campaign between 2010 and 2021 and investigating the relationship between different hand hygiene parameters based on data from participating healthcare facilities.

METHODS

A retrospective analysis was performed on datasets from HHEA forms, including data on hand hygiene compliance, alcohol-based handrub (ABHR) consumption, and Hand Hygiene Self-Assessment Framework (HHSAF) scores. Descriptive statistics were reported for each variable. The correlation between variables was inspected through Kendall's test, while possible non-linear relationships between hand hygiene compliance, ABHR consumption and HHSAF scores were sought through the Locally Estimated Scatterplot Smoothing or logistic regression models. A tree-structured partitioning model was developed to further confirm the obtained findings.

RESULTS

Ninety-seven healthcare facilities from 28 countries in three world regions (Asia-Pacific, Europe, Latin America) were awarded the HHEA and thus included in the analysis. HHSAF scores indicated an advanced hand hygiene promotion level (median 445 points, IQR 395-480). System change (100 [95-100] points) and institutional safety climate (85 [70-95] points) showed the highest and lowest score, respectively. In most cases, hand hygiene compliance was above 70%, with heterogeneity between countries. ABHR consumption above 20 millilitres per patient-day (ml/PD) was widely reported, with overall increasing trends. HHSAF scores were positively correlated with hand hygiene compliance (τ = 0.211, p = 0.007). We observed a positive correlation between compliance rates and ABHR consumption (τ = 0.193, p < 0.001), although the average predicted consumption was stable around 55-60 ml/PD for compliance rates above 80-85%. Logistic regression and partitioning tree analyses revealed that higher HHSAF scores were more likely in the high-ABHR consumption group at cut-offs around 57-59 ml/PD.

CONCLUSION

Ten years after its inception, the HHEA proves to be a valuable hand hygiene improvement programme in healthcare facilities worldwide. Consistent results were provided by the different hand hygiene indicators and the HHSAF score represents a valuable proxy measure of hand hygiene compliance.

Nursing strategies for the mechanically ventilated patient

The goal of this manuscript is to provide a comprehensive and multi-disciplinary review of the best nursing practices of caring for mechanically ventilated patients. By reviewing human medicine literature, the authors will extrapolate procedures that have been found to be most effective in reducing the risk of mechanical ventilation (MV) complications. Paired with review of the current standards in veterinary medicine, the authors will compile the best practice information on mechanically ventilated patient care, which will serve as a detailed resource for the veterinary nursing staff. Written from a nursing standpoint, this manuscript aims to consolidate the nursing assessment of a mechanically ventilated patient, addressing both systemic and physical changes that may be encountered during hospitalization. The goal of this review article is to present information that encourages a proactive approach to nursing care by focusing on understanding the effects of polypharmacy, hemodynamic changes associated with MV, complications of recumbent patient care, and sources of hospital acquired infections. When applied in conjunction with the more technical aspects of MV, this manuscript will allow veterinary technicians involved in these cases to understand the dynamic challenges that mechanically ventilated patients present, provide guidance to mitigate risk, address issues quickly and effectively, and create an up-to date standard of practice that can be implemented.

Economic evaluations of interventions to prevent and control health-care-associated infections: a systematic review

Almost 9 million health-care-associated infections have been estimated to occur each year in European hospitals and long-term care facilities, and these lead to an increase in morbidity, mortality, bed occupancy, and duration of hospital stay. The aim of this systematic review was to review the cost-effectiveness of interventions to limit the spread of health-care-associated infections), framed by WHO infection prevention and control core components. The Embase, National Health Service Economic Evaluation Database, Database of Abstracts of Reviews of Effects, Health Technology Assessment, Cinahl, Scopus, Pediatric Economic Database Evaluation, and Global Index Medicus databases, plus grey literature were searched for studies between Jan 1, 2009, and Aug 10, 2022. Studies were included if they reported interventions including hand hygiene, personal protective equipment, national-level or facility-level infection prevention and control programmes, education and training programmes, environmental cleaning, and surveillance. The British Medical Journal checklist was used to assess the quality of economic evaluations. 67 studies were included in the review. 25 studies evaluated methicillin-resistant Staphylococcus aureus outcomes. 31 studies evaluated screening strategies. The assessed studies that met the minimum quality criteria consisted of economic models. There was some evidence that hand hygiene, environmental cleaning, surveillance, and multimodal interventions were cost-effective. There were few or no studies investigating education and training, personal protective equipment or monitoring, and evaluation of interventions. This Review provides a map of cost-effectiveness data, so that policy makers and researchers can identify the relevant data and then assess the quality and generalisability for their setting.

Creating anti-viral high-touch surfaces using photocatalytic transparent films

Antimicrobial and self-cleaning surface coatings are promising tools to combat the growing global threat of infectious diseases and related healthcare-associated infections (HAIs). Although many engineered TiO₂-based coating technologies are reporting antibacterial performance, the antiviral performance of these coatings has not been explored. Furthermore, previous studies have underscored the importance of the "transparency" of the coating for surfaces such as the touch screens of medical devices. Hence, in this study, we fabricated a variety of nanoscale TiO₂-based transparent thin films (anatase TiO₂, anatase/rutile mixed phase TiO₂, silver-anatase TiO₂ composite, and carbon nanotube-anatase TiO₂ composite) via dipping and airbrush spray coating technologies and evaluated their antiviral performance (Bacteriophage MS2 as the model) under dark and illuminated conditions. The thin films showed high surface coverage (ranging from 40 to 85%), low surface roughness (maximum average roughness 70 nm), super-hydrophilicity (water contact angle 6-38.4°), and high transparency (70-80% transmittance under visible light). Antiviral performance of the coatings revealed that silver-anatase TiO₂ composite (nAg/nTiO₂) coated samples achieved the highest antiviral efficacy (5-6 log reduction) while the other TiO₂ coated samples showed fair antiviral results (1.5-3.5 log reduction) after 90 min LED irradiation at 365 nm. Those findings indicate that TiO₂-based composite coatings are effective in creating antiviral high-touch surfaces with the potential to control infectious diseases and HAIs.

Infection prevention and control: a guide for community nurses

The onset of the COVID-19 pandemic highlighted the importance of infection prevention and control (IPC), and accentuated the need for better health and safety measures to protect both healthcare professionals and their patients. In this article, Francesca Ramadan provides an overview of IPC measures for community nurses, such as hand hygiene and personal protective equipment, along with the safe management of care equipment and the care environment.

Hand Hygiene and Antimicrobial Resistance in the COVID-19 Era: An Observational Study

Hand hygiene (HH) is one of the most important infection prevention and control strategies at the hospital level. The aim of this study was to evaluate the potential COVID-19 pandemic impact on HH practices and rate of healthcare-associated infections. Data on alcohol-based handrub consumption (AHC) and antimicrobial resistance across 27 Italian hospitals over the period 2017–2021 were considered. Data on Methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteria (CRE) were extracted from the antimicrobial resistance regional surveillance system. A significant increase was highlighted, with a peak in 2020 and a partial fall in 2021 for AHC (p < 0.001). The decrease in MRSA rates in 2021 compared to 2017–2019 was significant (p = 0.013). A significant Spearman’s correlation between AHC and CRE rates was found (Spearman’s ρ −0.646, p = 0.032). This study supports the importance of AHC monitoring and showed that improving AHC was an attainable goal in the COVID-19 era. However, other strategies are needed to maintain the high levels of AHC attained during the pandemic, in order to avoid a progressive drop that has already begun in 2021. Furthermore, our results support the inverse relationship between AHC and infection rates and antimicrobial-resistant bacteria.

Cost-effectiveness analysis of a hand hygiene monitoring system in a tertiary pediatric hospital in Mexico

Background

An automated hand-hygiene monitoring system (AHHMS) was implemented in October 2019 at the Hospital Infantil de México Federico Gómez (HIMFG), a tertiary pediatric referral hospital, in four of the hospital wards with the highest rates of Healthcare Associated Infections (HAIs). The clinical and economic impact of this system had not yet been assessed prior to this study. This study aimed to evaluate if the AHHMS is a cost-effective alternative in reducing HAIs in the HIMFG.

Methodology

A full cost-effectiveness economic assessment was carried out for the hospital. The alternatives assessed were AHHMS implementation vis-a-vis AHHMS non-implementation (historical tendency). The outcomes of interest were infection rate per 1,000 patient-days and cost savings as a result of prevented infections. Infection rate data per 1,000 patient-days (PD) were obtained from the hospital's Department of Epidemiology with respect to the AHHMS. As regards historical tendency, an infection-rate model was designed for the most recent 6-year period. Infection costs were obtained from a review of available literature on the subject, and the cost of the implemented AHHMS was provided by the hospital. The assessment period was 6 months. The incremental cost-effectiveness ratio was estimated. Costs are reported in US Dollars (2021). Univariate sensitivity and threshold analysis for different parameters was conducted.

Results

The total estimated cost of the AHHMS alternative represented potential savings of $308,927–$546,795 US Dollars compared to non-implementation of the system (US$464,102 v. US$773,029–$1,010,898) for the period. AHHMS effectiveness was reflected in a diminished number of infections, 46–79 (−43.4–56.7%) compared to non-implementation (60 v. 106-139 infections).

Conclusion

The AHHMS was found to be a cost-saving alternative for the HIMFG given its cost-effectiveness and lower cost vis-a-vis the alternate option. Accordingly, the recommendation was made of extending its use to other areas in the hospital.

Hand hygiene compliance and its associated factors among health care providers in primary hospitals of Waghimira Zone, Northeast Ethiopia: a mixed study design

Introduction

Hand hygiene compliance is the problem of developing nations particularly in Sub-Saharan Africa including Ethiopia. Despite a lot of efforts have been employed, healthcare-associated infections are the existing health care problems, leading to impaired quality of life, prolonged hospital stays, increased healthcare costs, morbidity and mortality. This study aimed to assess the magnitude and factors associated with hand hygiene compliance among health care providers working at the primary hospitals of Waghimira Zone, Northeast Ethiopia.

Methods

Facility-based cross-sectional study design supplemented with qualitative research method was employed at the primary hospitals of Waghimira Zone from March 02–15, 2020. Simple random sampling using lottery method was applied to select 253 study participants. The data were coded on pre-arranged coding sheet and entered into Epi-Data version 3.1 and exported to SPSS version 25 for analysis. Descriptive statistics were displayed using tables and figures. Binary logistic regression analysis was used to test associations between the independent and the outcome variable. Multivariable logistic regression analysis was fitted to identify the independent predictors of hand-hygiene compliance at p-value < 0.05 and AOR with 95% confidence interval. Six Key Informant Interviews were conducted with purposively selected chief executive and clinical officers. Thematic content analysis was made and the findings were written sequentially with explanatory method.

Results

One-fifth of the subjects (20.6%, 95% CI = 15.2, 24.9) had good hand hygiene compliance. Attended training on hand hygiene protocol (AOR = 3.18, 95% CI: 1.39, 7.28), accessible to adequate soap and water (AOR = 3.77, 95%CI: 1.52, 9.37), having alcohol for hand rub (AOR = 2.67, 95%CI: 1.18, 6.05) and having hand wash sink (AOR = 2.31, 95%CI: 1.03, 5.14) were significantly associated with hand hygiene compliance which also supported by the qualitative findings.

Conclusions

Hand hygiene compliance among health care providers was low in the study area. Attended training on hand hygiene, accessibility to adequate soap and water, alcohol-based hand rub, and having hand washing sink in working area were statistically significant. Hence, the primary hospitals should be equipped with adequate supply to all the basic hand hygiene facilities.

Transparent, Robust, and Photochemical Antibacterial Surface Based on Hydrogen Bonding between a Si-Al and Cationic Dye

Healthcare-associated infections can occur and spread through direct contact with contaminated fomites in a hospital, such as mobile phones, tablets, computer keyboards, doorknobs, and other surfaces. Herein, this study shows a transparent, robust, and visible light-activated antibacterial surface based on hydrogen bonds between a transparent silica-alumina (Si-Al) sol-gel and a visible light-activated photosensitizer, such as crystal violet (CV). The study of the bonding mechanisms revealed that hydrogen bonding predominantly occurs between the N of CV and Al-OH. Apart from CV, Si-Al can be combined with a variety of dyes, highlighting its potential for wide application. The Si-Al@CV film selectively generates singlet oxygen using ambient visible light, triggering potent photochemical antibacterial performance against Gram-positive and Gram-negative bacteria. Additionally, the Si-Al@CV film is stable even after mechanical stability tests such as tape adhesion, scratch, bending, and water immersion. In vitro cytotoxicity tests using C2C12 myoblast cells showed that the Si-Al@CV film is a biocompatible material. This work suggests a new approach for designing a transparent and robust touchscreen surface with photochemical antibacterial capability against healthcare-associated infections.

Patient Safety in Anesthesia: Hand Hygiene and Perioperative Infection Control

Purpose of Review

This review highlights the importance of the anesthesia team in minimizing perioperative infection risks and prevention of surgical site infection. Due to the immense financial and patient care burden that results from perioperative infection, a foundational knowledge in preventive measures is essential.

Recent Findings

Perioperative infection control, the role of the anesthesia team in reducing infection risk, and more specifically the outsized importance of hand hygiene in this space have become increasingly apparent. Maintenance of workspace cleanliness along with hand hygiene forms the cornerstone of preventing microbial transmission. Unfortunately, improvements around perioperative infection control are lacking.

Summary

The importance of the anesthesia team in maintaining proper hand hygiene, a clean work environment, and appropriate patient conditions to minimize risk of perioperative infection cannot be overstated. Poor clinical outcomes, economic burden, and external pressure from payers highlight the need for anesthesia providers to have an up-to-date knowledge of best practices in this area. In this article, we will review the current recommendations for hand hygiene practices and perioperative infection prevention.

Compliance of Nurses with Hand Hygiene Guidelines in Tripoli University Hospital, 2019

Background Health care-associated infections (HAIs) result in high morbidity, decreased personal satisfaction, and mortality. Implementing infection prevention and control strategies such as hand hygiene (HH) promotion is critical to reduce the risk of the HAI and protect patients.

Aims This study aimed to determine the compliance rate of HH among nurses in Tripoli University Hospital (TUH, previously known as Tripoli Medical Center).

Method A cross-sectional study was conducted in different departments at TUH, starting from May 1st to October 31st, 2019. An observational checklist based on the “five moments for hand hygiene” of World Health Organization (WHO) was used. There were 271 nurses who interacted with 1,213 patients, a total of 3,452 HH episodes, and 6,065 cases of HH that were collected in this study, and data were statistically analyzed.

Results The overall HH compliance rate was 56.9%. Most of the nurses (86%) preferred to use HH after contact with individual patients and 71.6% after contact with patients' environment. There was, however, low percentage of HH prior to patient contact (35.1%). The compliance rate was higher among nurses of the age group of less than 20 years (60.8%), non-Libyan (60.7%), and those who received formal training (60.5%).

Conclusion In general, the HH compliance rate was low among nurses working in TUH. Education is an important factor that impacts the practice of HH pre- and postpatient contact. Wider studies that include assessment of pre- and posteducation courses should be conducted in the future.

Implementation of hand hygiene in health-care facilities: results from the WHO Hand Hygiene Self-Assessment Framework global survey 2019

BACKGROUND

Hand hygiene is at the core of effective infection prevention and control (IPC) programmes. 10 years after the development of the WHO Multimodal Hand Hygiene Improvement Strategy, we aimed to ascertain the level of hand hygiene implementation and its drivers in health-care facilities through a global WHO survey.

METHODS

From Jan 16 to Dec 31, 2019, IPC professionals were invited through email and campaigns to complete the online Hand Hygiene Self-Assessment Framework (HHSAF). A geospatial clustering algorithm selected unique health-care facilities responses and post-stratification weighting was applied to improve representativeness. Weighted median HHSAF scores and IQR were reported. Drivers of the HHSAF score were determined through a generalised estimation equation.

FINDINGS

3206 unique responses from 90 countries (46% WHO Member States) were included. The HHSAF score indicated an intermediate hand hygiene implementation level (350 points, IQR 248-430), which was positively associated with country income level and health-care facility funding structure. System Change had the highest score (85 points, IQR 55-100), whereby alcohol-based hand rub at the point of care has become standard practice in many health-care facilities, especially in high-income countries. Institutional Safety Climate had the lowest score (55 points, IQR 35-75). From 2015 to 2019, the median HHSAF score in health-care facilities participating in both HHSAF surveys (n=190) stagnated.

INTERPRETATION

Most health-care facilities had an intermediate level of hand hygiene implementation or higher, for which health-care facility funding and country income level were important drivers. Availability of resources, leadership, and organisational support are key elements to further improve quality of care and provide access to safe care for all.

FUNDING

WHO, Geneva University Hospitals and Faculty of Medicine, and WHO Collaborating Center on Patient Safety, Geneva, Switzerland.

Hand hygiene practices for prevention of health care-associated infections associated with admitted infectious patients in the emergency department: a systematic review

Background

In most high-income countries, emergency departments (ED) represent the principal point of access forcer by critically ill or injured patients. Unlike inpatient units, ED healthcare workers (ED HCWs) have demonstrated relative lack of adherence to hand hygiene (HH) guidelines, commonly citing frequency of intervention and high rates of admission, which reflect severity of cases encountered.

Aim

Assessment of studies on hand hygiene compliance (HHC) by ED HCWs conducted between 2010 and 2020, seeking to estimate HHC rates and intervention strategies utilised to improve HHC in EDs.

Methods

Searches conducted in Web of Science, EBSCO HOST (CINHAL & Medline), PubMed, Embase, and Cochrane for full studies published between 2010 and 2020 on the topic of HHC in the ED.

Results

One hundred twenty-nine eligible articles were identified of which 79 were excluded. Fifty-one underwent full-text screening before 20 studies were deemed relevant. Of the eligible studies, fifteen (75%) had, as the primary outcome, HHC according to the WHO-recommended 5-moments. Twelve studies (60%) implemented multimodal or single intervention strategies. Eight studies were ambiguous regarding the nature of the approach adopted. In the nine observational studies where HHC was documented, an overall post-intervention median HHC rate of 45% (range 8–89.7%).

Conclusion

Multimodal approaches appear to have enhanced HHC moderately among ED HCWs. Elevated complexity associated with critically ill patients, and ED overcrowding, are contributing factors to relatively low compliance rates observed. Strategies to improve HHC rates may need to acknowledge, and cater for, the context of an unpredictable environment.

Alcohol-Based Hand Rub Consumption and World Health Organization Hand Hygiene Self-Assessment Framework: A Comparison Between the 2 Surveillances in a 4-Year Region-Wide Experience

OBJECTIVES

Hand hygiene is essential for infection prevention. In Piedmont (Northwest Italy), hand hygiene is routinely monitored through 2 surveillance systems, the World Health Organization Hand Hygiene Self-Assessment Framework (HHSAF) and alcohol-based hand rub (ABHR) consumption. This study was aimed at (1) comparing the results of these surveillances, investigating the consistence of the 2 systems and (2) inquiring whether organizational differences among healthcare facilities significantly affected hand hygiene performances.

METHODS

A retrospective analysis was performed on data collected annually from 2015 to 2018 for both surveillances from 40 hospitals of the region: HHSAF score (500 points maximum) and ABHR consumption in milliliters per patient-day (mL/PD) were considered. Logistic regression models were built to evaluate possible correlations between these variables, and observations were clustered considering both variables to identify whether groups with significant differences could be discerned. A tree-structured partitioning model was used to confirm the obtained results.

RESULTS

A positive correlation was observed between HHSAF score and odds of belonging to the high ABHR consumption group, particularly for cutoffs set to 19 to 23 mL/PD (P = 0.033 for 23 mL/PD). Two ABHR consumption peaks were identified at approximately 10 and 22 mL/PD, corresponding to median HHSAF scores of 353.75 and 375 points, respectively. The group with better performances was mainly composed of hub hospitals (with single-hospital management).

CONCLUSIONS

The 2 surveillance systems are consistent, and the HHSAF score could work as a reasonable predictor of hand hygiene compliance in healthcare settings. Different management characteristics are crucial in creating a more/less favorable environment for hand hygiene compliance and infection prevention.

Compliance to hand hygiene and its determinant factors among Community Health Care Providers in Community Clinics: an observational study in Bangladesh

Background

Healthcare-associated infections caused by poor hand hygiene (HH) practices can affect both the care seekers and the health care providers (HCPs) while providing primary health care. No study has been conducted on the compliance of HH practices among the primary level HCPs in Bangladesh.

Objective

The study aimed to assess the compliance rates of HH and its determinant factors among Community Health Care Providers (CHCPs) in Community Clinics (CC).

Methods

A cross-sectional study was conducted from September 2019 to February 2020 among 150 randomly selected CHCPs with functional HH facilities in Patuakhali district, Bangladesh. Structured interviews and observation tools were used to collect data.

Results

Good HH compliance among CHCPs was found to be 16.7% (95% CI: 11.3-21.3). Out of all 1218 possible HH opportunities, only 255 (20.9%) resulted in any HH action. Presence of 70% alcohol-based hand sanitiser at the point of care (aOR: 6.4, 95% CI: 1.1-38.3), HH training (aOR: 4.6, 95% CI: 1.1-18.9), displayed visual cues (aOR: 4.4, 95% CI: 1.1-17.7), knowledge about HH (aOR: 3.8, 95% CI: 1.1-13.6) and number of HH opportunities (aOR: 0.6, 95% CI: 0.4-0.8) were factors associated with HH compliance.

Discussion

Overall HH compliance among CHCPs was relatively low. It was recommended to implement multimodal HH improvement strategies, including a continuous training program, supply of alcohol-based hand rub, reminder, provision of five moments of HH in the training modules and feedback on HH performance.

Perform hand hygiene and the doors will open - the effectiveness of new system implementation on Paediatric Intensive Care Unit visitors' handwashing compliance

Hand hygiene (HH) performance on entering intensive care units (ICUs) is commonly accepted but often inadequately performed. We developed a simple, inexpensive module that connects touchless dispensers of alcohol sanitiser (TDAS) to the automatic doors of a paediatric ICU, and assessed the impact of this intervention on HH compliance of hospital staff and visitors. A prospective observational study was conducted over a 3-week period prior to the intervention, followed by a 4-week period post intervention. HH performance was monitored by a research assistant whose office location enabled direct and video-assisted observation of the ICU entrance. A total of 609 entries to the ICU was recorded. Overall HH performance was 46.9% (92/196) before and 98.5% (406/413) after the intervention. Our findings suggest that HH performance on entering an ICU can be improved via a mechanism that makes operation of an automatic door dependent on use of a TDAS system, and thus contribute to infection control.

COVID-19 Lesson for Respiratory Syncytial Virus (RSV): Hygiene Works

Respiratory syncytial virus (RSV) is a leading cause of acute lower respiratory tract infections (LRTIs) in infants worldwide. The global direct medical cost associated with RSV LRTIs reaches billions of dollars, with the highest burden in low–middle-income countries. Many efforts have been devoted to improving its prevention and management, including both non-pharmaceutical and pharmaceutical strategies, often with limited routine use in high-income countries due to high costs. During the ongoing COVID-19 pandemic, a dramatic decrease in RSV infections (up to 70–90%) has been reported around the globe, directly related to the implementation of containment measures (face masks, hand hygiene, and social distancing). Primary prevention has demonstrated the highest cost effectiveness ratio in reducing the burden of a respiratory infection such as RSV, never reached before. Thus, we emphasize the importance of non-pharmaceutical preventive hygiene measures that should be implemented and maintained even after the COVID-19 outbreak.

What are healthcare workers' preferences for hand hygiene interventions? A discrete choice experiment

OBJECTIVES

To understand the key attributes in designing effective interventions for improving healthcare workers' (HCWs') hand hygiene compliance and HCWs' preference for these attributes.

DESIGN

A discrete choice experiment (DCE) was conducted with five attributes extracted from the framework of Total Quality Management that can be applied in the design of hand hygiene interventions. They were hand hygiene monitoring, open discussion, message framing, resources accessibility and top management involvement. An addition attribute, peer hand hygiene performance, was considered as a contextual factor. Data were analysed by a conditional logit model to evaluate how these attributes impact HCWs' hand hygiene compliance.

SETTING

The DCE was conducted with participants from a university hospital in Taichung.

PARTICIPANTS

HCWs involved in daily patient-care activities (N=387).

RESULTS

To enhance their compliance, HCWs had strong and consistent preferences in having open discussion of hand hygiene problems ([Formula: see text], [Formula: see text]), easy access to hand hygiene resources ([Formula: see text], [Formula: see text]) and top management involvement ([Formula: see text], [Formula: see text]). For hand hygiene monitoring ([Formula: see text], [Formula: see text]), HCWs preferred to be monitored by infection control staff over their department head if their peer hand hygiene performance was low. On the other hand, when the peer performance was high, monitoring by their department head could improve their hand hygiene compliance. Similarly, how educational messages were framed impacted compliance and also depended on the peer hand hygiene performance. When the peer performance was low, HCWs were more likely to increase their compliance in reaction to loss-framed educational messages ([Formula: see text],[Formula: see text]). When the peer performance was high, gain-framed messages that focus on the benefit of compliance were more effective in inducing compliance.

CONCLUSIONS

Each intervention design has its unique impact on HCWs' hand hygiene compliant behaviour. The proposed approach can be used to evaluate HCWs' preference and compliance of an intervention before it is implemented.

HAND HYGIENE COMPLIANCE IN THE PREVENTION OF HOSPITAL ACQUIRED INFECTIONS: A SYSTEMATIC REVIEW

BACKGROUND

Healthcare worker's (HCW) hands are known to be a primary source of transmission of hospital-acquired infections (HAIs). Thus, practicing hand hygiene (HH) and adhering to HH guidelines are both expected to decrease the risk of transmission but there is no consensus on the optimal hand hygiene compliance (HHC) rate that HCWs should aim for.

AIM

The objective of this study was to systematically review the published literature to determine an optimal threshold of HCW HHC rate associated with the lowest incidence rate of HAIs.

METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. We searched online databases using a comprehensive search criterion for randomized controlled trials and non-randomized controlled studies, investigating the impact of HCW's HHC rate on HAI rates in patients of all ages, within healthcare facilities in high income countries.

FINDINGS

Of the 8,093 articles citations and abstracts screened, 35 articles were included in the review. Most studies reported overall HAIs per 1000 patient-days and device-associated HAIs per 1000 device-days. Most studies reported HHC rates between 60%-70%. Lower incidence HAI rates seemed to be achieved with HHC rates of approximately 60%. Studies included were not originally designed to assess the impact of HHC on HAI rates but risk of bias was assessed as per our predetermined exposure and outcome criterion. 11 (31%) of studies were deemed at low risk of bias.

CONCLUSIONS

Although HHC is part of HCW's code of conduct, very high HHC rates were difficult to reach. In observational studies, HHC and HAI followed a negative relationship up to about 60%. Due to flaws in study design, causality could not be inferred; only general trends could be discussed. Given the limitations, there is a need for high-quality evidence to support the implementation of specified targets of HHC rates.

Barriers and facilitators on hand hygiene and hydro-alcoholic solutions' use: representations of health professionals and prevention perspectives

Background

Healthcare-associated infections pose a serious problem in terms of health and mortality. Their prevention is a necessity, and healthcare professionals are one of their main vectors. Thus, they must be at the centre of preventative strategies. As hydro-alcoholic solutions (alcohol-based hand rub) represent the most effective means of preventing these infections, it is necessary to identify the representations, barriers, and facilitators of their use.

Method

Forty-six healthcare professionals from two areas in France, New Aquitaine and Guadeloupe, were questioned about their practices through semi-structured registered interviews and four focus groups. Each interview and focus group were transcribed then analysed through lexicometric and thematic content analyses.

Results

The interviewed identified several barriers and facilitators related to the composition and characteristics of hydro-alcoholic solutions (unpleasantness, harmfulness, personal preferences for other hand hygiene products), personal factors (work habits, cognitive bias, lack of knowledge and communication) and organizational (professional constraints, product accessibility, financial resources).

Conclusion

Strategies to prevent healthcare-associated infections should be constructed with consideration of psychosocial facilitators and barriers for healthcare professionals in using hydro-alcoholic solutions. These strategies should also ensure that they are well informed about the effectiveness of alcohol-based solutions, through prevention campaigns and scientific articles. This awareness should equally be conveyed with educational tools that involve healthcare professionals and use the social dynamics of their work environment.

Hand-hygiene-related clinical trials reported between 2014 and 2020: a comprehensive systematic review

Background

There is general consensus that hand hygiene is the most effective way to prevent healthcare-associated infections. However, low rates of compliance amongst healthcare workers have been reported globally. The coronavirus disease 2019 pandemic has further emphasized the need for global improvement in hand hygiene compliance by healthcare workers.

Aim

This comprehensive systematic review provides an up-to-date compilation of clinical trials, reported between 2014 and 2020, assessing hand hygiene interventions in order to inform healthcare leaders and practitioners regarding approaches to reduce healthcare-associated infections using hand hygiene.

Methods

CINAHL, Cochrane, EMbase, Medline, PubMed and Web of Science databases were searched for clinical trials published between March 2014 and December 2020 on the topic of hand hygiene compliance among healthcare workers. In total, 332 papers were identified from these searches, of which 57 studies met the inclusion criteria.

Findings

Forty-five of the 57 studies (79%) included in this review were conducted in Asia, Europe and the USA. The large majority of these clinical trials were conducted in acute care facilities, including hospital wards and intensive care facilities. Nurses represented the largest group of healthcare workers studied (44 studies, 77%), followed by physicians (41 studies, 72%). Thirty-six studies (63%) adopted the World Health Organization's multi-modal framework or a variation of this framework, and many of them recorded hand hygiene opportunities at each of the ‘Five Moments’. However, recording of hand hygiene technique was not common.

Conclusion

Both single intervention and multi-modal hand hygiene strategies can achieve modest-to-moderate improvements in hand hygiene compliance among healthcare workers.

Observational study of compliance with infection control practices among healthcare workers in subsidized and private residential care homes

Background

The elderly population in Hong Kong is rapidly growing, and the need for residential care homes (RCHs) is increasing. The risk of being infected with micro-organisms increases among the frail and the vulnerable elderly population as their immunity system begins to deteriorate. Furthermore, the residents in RCHs are at high risk of healthcare-associated infections (HAIs) due to the confined living environments and individual co-morbidities. In relation to this, infection control practice (ICP) is considered a crucial and effective approach in preventing HAIs. This study aimed to observe the daily ICP of healthcare workers in RCH settings.

Methods

An observational study was conducted to observe daily ICP among healthcare workers in private and subsidized RCHs. Each RCH was separated into different units based on the location (common area and bedroom area) and nature of residents for successive days. The ICP episodes were observed until 200 opportunities in each unit. The ICP episodes were recorded by an electronic tool called “eRub,” which is an ICP checklist based on international guidelines.

Results

The most frequent observed ICP episodes were hand hygiene (n = 1053), the use of gloves (n = 1053) and respiratory protection (n = 1053). The overall compliance of hand hygiene was poor, with only 15% of participants performing this during the “five moments for hand hygiene.” Furthermore, the observations showed that 77.9% improperly performed the use of gloves, and 31.8% failed to wear a mask during the care provision for the elderly. However, the results showed that most healthcare workers can wear the mask in a proper way when they should. Generally, the personal care workers were the worst in terms of hand hygiene and use of gloves compared with the other types of healthcare workers.

Conclusions

Despite the fact that the practice of hand hygiene, the use of gloves, and respiratory protection were the important elements of ICP, overall compliance to these elements was still poor. Personal care workers had the most frequent contact with the residents, but they had the worst compliance rate. Hence, continued monitoring and training among healthcare workers is needed, particularly personal care workers, in this healthcare service setting.

Evolution and associated factors of hand hygiene compliance in a pediatric tertiary hospital

BACKGROUND

The objective is to know the evolution of the Degree of Compliance with Recommendations (DCR) on hand hygiene (HH) and its associated factors in the pediatric care areas (PCAs) of a tertiary hospital.

METHODS

Observational, cross-sectional study, repeated over time, with direct observation of the DCR on HH during the daily activity of health care workers. Over 13 years, 9226 HH opportunities were observed. Associations between DCR, PCA and other variables (eg, age, sex, and professional position) were examined using χ² and adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

DCR on HH in 9 PCAs was 64.3% (95% CI, 63.3-65.3), and in the group of non-pediatric areas it was 49.6% (95% CI, 49.1-50.1). The areas with the highest degree of compliance were Oncology 72.8% (95% CI, 69.2-76.4), Neonatology 73.2% (95% CI, 71.3-75.1), and Neonatal intensive care unit 70.0% (95% CI, 67.5-72.6). These were the areas with the strongest association with HH compliance, with aOR:2.8 (95% CI, 2.2-3.6); aOR, 3.0 (95% CI, 2.6-3.6) aOR:2.6 (95% CI, 2.1-3.1), respectively. Other associated factors were the indications "after an activity," aOR, 1.6 (95% CI, 1.5-1.8) and the availability of pocket-size alcohol-based solution, aOR, 2.1(95% CI, 1.9-2.3).

CONCLUSIONS

The DCR on HH in PCAs is higher than in other areas, although there is still margin for improvement. We have identified modifiable factors that have an independent association with HH compliance in PCAs. Focusing on modifiable factors will increase compliance with HH with the ultimate goal of reducing healthcare associated infections.

Evaluation of the Cost-effectiveness of Infection Control Strategies to Reduce Hospital-Onset Clostridioides difficile Infection

Importance

Clostridioides difficile infection is the most common hospital-acquired infection in the United States, yet few studies have evaluated the cost-effectiveness of infection control initiatives targeting C difficile.

Objective

To compare the cost-effectiveness of 9 C difficile single intervention strategies and 8 multi-intervention bundles.

Design, Setting, and Participants

This economic evaluation was conducted in a simulated 200-bed tertiary, acute care, adult hospital. The study relied on clinical outcomes from a published agent-based simulation model of C difficile transmission. The model included 4 agent types (ie, patients, nurses, physicians, and visitors). Cost and utility estimates were derived from the literature.

Interventions

Daily sporicidal cleaning, terminal sporicidal cleaning, health care worker hand hygiene, patient hand hygiene, visitor hand hygiene, health care worker contact precautions, visitor contact precautions, C difficile screening at admission, and reduced intrahospital patient transfers.

Main Outcomes and Measures

Cost-effectiveness was evaluated from the hospital perspective and defined by 2 measures: cost per hospital-onset C difficile infection averted and cost per quality-adjusted life-year (QALY).

Results

In this agent-based model of a simulated 200-bed tertiary, acute care, adult hospital, 5 of 9 single intervention strategies were dominant, reducing cost, increasing QALYs, and averting hospital-onset C difficile infection compared with baseline standard hospital practices. They were daily cleaning (most cost-effective, saving $358 268 and 36.8 QALYs annually), health care worker hand hygiene, patient hand hygiene, terminal cleaning, and reducing intrahospital patient transfers. Screening at admission cost $1283/QALY, while health care worker contact precautions and visitor hand hygiene interventions cost $123 264/QALY and $5 730 987/QALY, respectively. Visitor contact precautions was dominated, with increased cost and decreased QALYs. Adding screening, health care worker hand hygiene, and patient hand hygiene sequentially to the daily cleaning intervention formed 2-pronged, 3-pronged, and 4-pronged multi-intervention bundles that cost an additional $29 616/QALY, $50 196/QALY, and $146 792/QALY, respectively.

Conclusions and Relevance

The findings of this study suggest that institutions should seek to streamline their infection control initiatives and prioritize a smaller number of highly cost-effective interventions. Daily sporicidal cleaning was among several cost-saving strategies that could be prioritized over minimally effective, costly strategies, such as visitor contact precautions.

Biosafety of Non-Return Valves for Infusion Systems in Radiology

Cross-infection in contrast injectors is still a subject under discussion with little understanding. This study evaluated the biosafety of non-return valves (NRVs). Initially, the maximum pressure during backflow of intact and disrupted flexible diaphragms (FDs) from NRVs, as well as the functionality of connectors with NRVs were verified. The performance of air columns interposed by water in connectors with NRVs was analyzed, and the diffusion distance of crystal violet through connectors with NRVs was measured. The efficacy of NRVs as a barrier to bacterial contamination from backflow was evaluated. Finally, a clinical study of bacteriological contamination from syringes was conducted. There were differences among the maximum tolerated pressure by intact and disrupted FDs. Disrupted FDs showed no failures in the functionality of connectors with NRVs based on the lack of air bubbles released. Air columns could move through connectors with NRVs with intact and disrupted FDs. The longest diffusion distance of crystal violet was 6 cm of connector length, and NRVs showed efficacy as a barrier to bacterial contamination. In the clinical study, there was no bacterial growth in any of the evaluated samples. In conclusion, biosafety depends on the functionality of NRVs as well as proper practical clinical performance.

Hand hygiene compliance monitoring: Do video-based technologies offer opportunities for the future?

Hand hygiene is universally recognised as the primary measure to reduce healthcare-associated infections. Studies have convincingly demonstrated a link between increased hand hygiene compliance and reductions in rates of healthcare-associated infections. Direct observation is considered the gold standard method for monitoring hand hygiene compliance. Despite the acknowledged benefits of this approach, recent literature has highlighted a range of issues impacting on the reliability and validity of this data collection technique. The rise of technology in healthcare provides opportunity for alternative methods that promise advantages over direct human observation. There have been no published examples of systems that are able to capture data consistent with all the WHO '5 Moments for Hand Hygiene'. In this paper we explore current human-based auditing practises for monitoring hand hygiene compliance and raise for discussion and debate video-based technologies to monitor hand hygiene compliance. We raise questions regarding hybrid approaches that incorporate both direct human observation and indirect video-based surveillance, and the possible advantages and disadvantages therein for monitoring hand hygiene compliance. We suggest that such methods have the potential to ameliorate, or minimise, the inherent biases associated with direct observation, notably the Hawthorne Effect. Future research into the utility of a hybrid approach to auditing, including the technical specifications, efficacy, cost effectiveness and acceptability of such a model is warranted.

Hand hygiene compliance and associated factors among health care providers in Central Gondar zone public primary hospitals, Northwest Ethiopia

Background

Poor hand hygiene compliance is one in all the leading contributory factors to healthcare-associated infections. This is an important source of complications across the continuum of care and poses a serious threat to people admitted to hospitals. However, the magnitude and associated factors of hand hygiene compliance in public primary hospitals were not well investigated in Ethiopia. Therefore, this study was conducted to assess hand hygiene compliance and associated factors among health care providers in Central Gondar Zone public primary hospitals, Northwest Ethiopia.

Methods

An Institutional based cross-sectional study was conducted from March to April 2019 among health care providers. The data were collected using self-administered questionnaires and observational checklists. Using Epi Info 3.1, data was entered and analyzed using SPSS version 23. The data were analyzed using descriptive statistics and logistic regression models. A p-value less than 0.05 with 95% confidence interval was used to declare statistical significance.

Results

Of 335 study participants, 50 (14.9%), had good hand hygiene compliance. Training on hand hygiene (AOR = 8.07, 95%CI: 2.91, 22.39), availability of adequate soap and water for hand hygiene (AOR = 5.10, 95%CI: 1.93, 13.52), availability of alcohol-based hand rub (AOR = 3.23, 95%CI: 1.32, 7.92), knowledge about hand hygiene (AOR = 6.74, 95%CI: 2.96, 15.34) and attitude towards hand hygiene (AOR = 2.15, 95%CI: 1.04, 4.46) were factors associated with hand hygiene compliance.

Conclusion

The overall level of hand hygiene compliance among health care providers was poor. Training, availability of adequate soap and water, availability of alcohol-based hand rub, knowledge on hand hygiene, and attitude of health care providers were significantly associated with hand hygiene compliance.

Modelling the costs and consequences of reducing healthcare-associated infections by improving hand hygiene in an average hospital in England

OBJECTIVE

To assess the potential clinical and economic impact of introducing an electronic audit and feedback system into current practice to improve hand hygiene compliance in a hypothetical general hospital in England, to reduce the incidence of healthcare-associated infections (HCAIs).

METHODS

Decision analysis estimated the impact of introducing an electronic audit and feedback system into current practice to improve hand hygiene compliance among front-line healthcare practitioners (HCPs).

RESULTS

The model assumed 4.7% of adult inpatients (ie, ≥18 years of age) and 1.72% of front-line HCPs acquire a HCAI in current practice. The model estimated that if use of the electronic audit and feedback system could lead to a reduction in the incidence of HCAIs of between 5% and 25%, then the annual number of HCAIs avoided could range between 184 and 921 infections per hospital and HCAI-related mortality could range between 6 and 31 deaths per annum per hospital. Additionally, up to 86 days of absence among front-line HCPs could be avoided and up to 7794 hospital bed days could be released for alternative use. Accordingly, the total annual hospital cost attributable to HCAIs could be reduced by between 3% and 23%, depending on the effectiveness of the electronic audit and feedback system. If introduction of the electronic audit and feedback system into current practice could lead to a reduction in the incidence of HCAIs by at least 15%, it would have a ≥0.75 probability of affording the National Health Service (NHS) a cost-effective intervention.

CONCLUSION

If the introduction of the electronic audit and feedback system into current practice in a hypothetical general hospital in England can improve hand hygiene compliance among front-line HCPs leading to a reduction in the incidence of HCAIs by ≥15%, it would potentially afford the NHS a cost-effective intervention.

Effectiveness over time of a multimodal intervention to improve compliance with standard hygiene precautions in an intensive care unit of a large teaching hospital

Background

Standard hygiene precautions are an effective way of controlling healthcare-associated infections. Nevertheless, compliance with hand hygiene (HH) guidelines among healthcare workers (HCWs) is often poor, and evidence regarding appropriate use of gloves and gowns is limited and not encouraging. In this study, we evaluated the ability over time of a multimodal intervention to improve HCWs compliance with standard hygiene precautions.

Methods

Trend analysis of direct observations of compliance with HH guidelines and proper glove or gown use was conducted in the medical/surgical intensive care unit (ICU) of Umberto I Teaching Hospital of Sapienza University of Rome. The study consisted of two phases: a six-month baseline phase and a 12-month post-intervention phase. The multimodal intervention was based on the World Health Organization strategy and included education and training of HCWs, together with performance feedback.

Results

A total of 12,853 observations were collected from November 2016 to April 2018. Overall compliance significantly improved from 41.9% at baseline to 62.1% (p < 0.001) after the intervention and this improvement was sustained over the following trimesters. Despite variability across job categories and over the study period, a similar trend was observed for most investigations. The main determinants of compliance were job category (with nurses having the highest compliance rates), being a member of ICU staff and whether delivering routine, as opposed to emergency, care. HH compliance was modified by glove use; unnecessary gloving negatively affected HH behaviour while appropriate gloving positively influenced it.

Conclusions

The multimodal intervention resulted in a significant improvement in compliance with standard hygiene precautions. However, regular educational reinforcement and feedback is essential to maintain a high and uniform level of compliance.

Healthcare-associated infections in intensive care units in Taiwan, South Korea, and Japan: recent trends based on national surveillance reports

Background

Sustainable systematic interventions are important for infection prevention and control (IPC). Data from surveillance of healthcare-associated infections (HAI) provides feedback for implementation of IPC programs. To address the paucity of such data in Asia, we searched for national HAI surveillance and IPC programs in this region.

Methods

Data were analysed from open access national surveillance reports of three Asian countries: Taiwan, South Korea and Japan from 2008 to 2015. National IPC programs were identified.

Results

There were differences among the countries in surveillance protocols, hospital coverage rates, and national IPC policies and programs. Nevertheless, there was a 53.0% reduction in overall HAI over the 8-year period. This consisted of a decrease from 9.34 to 5.03 infections per 1000 patient-days in Taiwan, from 7.56 to 2.76 in Korea, and from 4.41 to 2.74 in Japan (Poisson regression, all p < 0.05). Across the three countries, Escherichia coli and Candida albicans were the major pathogens for urinary tract infection. Staphylococcus aureus, Acinetobacter baumannii and Enterococcus faecium were common bloodstream pathogens. For pneumonia, S. aureus, A. baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae were the predominant pathogens, with considerable country differences. There was a 64.6% decrease in the number of isolates of methicillin-resistant S. aureus, 38.4% decrease in carbapenem-resistant P. aeruginosa and 49.2% decrease in carbapenem-resistant A. baumannii (CRAB) in Taiwan (all p < 0.05), and similarly in Korea with the exception of CRAB (30.5 and 50.4% reduction, respectively, both p < 0.05).

Conclusion

We found a significant decrease in HAI across the three countries in association with sequential multifaceted interventions such as hand hygiene, care bundles, and antimicrobial stewardships. Further regional collaboration could be forged to develop joint strategies to prevent HAI.

Everybody hands-on to avoid ESKAPE: effect of sustained hand hygiene compliance on healthcare-associated infections and multidrug resistance in a paediatric hospital

PURPOSE

Hand hygiene is the most important strategy for preventing healthcare-associated infections (HCAIs); however, the impact of hand hygiene in middle-income countries has been poorly described. In this work, we describe the impact of the programme 'Let's Go for 100' on hand hygiene adherence, HCAIs rates and multidrug-resistant (MDR) bacteria, including the molecular typing of methicillin-resistant Staphylococcus aureus (MRSA) strains.

METHODOLOGY

A multimodal, hospital-wide hand hygiene programme was implemented from 2013. 'Let's Go for 100' involved all healthcare workers and encompassed education, awareness, visual reminders, feedback and innovative strategies. Monthly hand hygiene monitoring and active HCAI surveillance were performed in every ward. Molecular typing of MRSA was analysed by pulsed-field gel electrophoresis (PFGE).Results/Key findings. Hand hygiene adherence increased from 34.9 % during the baseline period to 80.6 % in the last 3 months of this study. The HCAI rate decreased from 7.54 to 6.46/1000 patient-days (P=0.004). The central line-associated bloodstream infection (CLABSIs) rate fell from 4.84 to 3.66/1000 central line-days (P=0.05). Negative correlations between hand hygiene and HCAIs rates were identified. The attack rate of MDR-ESKAPE group bloodstream infections decreased from 0.54 to 0.20/100 discharges (P=0.024). MRSA pulsotypes that were prevalent during the baseline period were no longer detected after the 5^th quarter, although new strains were identified.

CONCLUSIONS

A multimodal hand hygiene programme in a paediatric hospital in a middle-income country was effective in improving adherence and reducing HCAIs, CLABSIs and MDR-ESKAPE bloodstream infections. Sustaining hand hygiene adherence at a level of >60 % for one year limited MRSA clonal transmission.

Cost-effectiveness of interventions to improve hand hygiene in healthcare workers in middle-income hospital settings: a model-based analysis

BACKGROUND

Multi-modal interventions are effective in increasing hand hygiene (HH) compliance among healthcare workers, but it is not known whether such interventions are cost-effective outside high-income countries.

AIM

To evaluate the cost-effectiveness of multi-modal hospital interventions to improve HH compliance in a middle-income country.

METHODS

Using a conservative approach, a model was developed to determine whether reductions in meticillin-resistant Staphylococcus aureus bloodstream infections (MRSA-BSIs) alone would make HH interventions cost-effective in intensive care units (ICUs). Transmission dynamic and decision analytic models were combined to determine the expected impact of HH interventions on MRSA-BSI incidence and evaluate their cost-effectiveness. A series of sensitivity analyses and hypothetical scenarios making different assumptions about transmissibility were explored to generalize the findings.

FINDINGS

Interventions increasing HH compliance from a 10% baseline to ≥20% are likely to be cost-effective solely through reduced MRSA-BSI. Increasing compliance from 10% to 40% was estimated to cost US$2515 per 10,000 bed-days with 3.8 quality-adjusted life-years (QALYs) gained in a paediatric ICU (PICU) and US$1743 per 10,000 bed-days with 3.7 QALYs gained in an adult ICU. If baseline compliance is not >20%, the intervention is always cost-effective even with only a 10% compliance improvement.

CONCLUSION

Effective multi-modal HH interventions are likely to be cost-effective due to preventing MRSA-BSI alone in ICU settings in middle-income countries where baseline compliance is typically low. Where compliance is higher, the cost-effectiveness of interventions to improve it further will depend on the impact on hospital-acquired infections other than MRSA-BSI.

Strategies to improve hand hygiene compliance among healthcare workers in adult intensive care units: a mini systematic review

BACKGROUND

Hand hygiene compliance among healthcare workers (HCWs) in intensive care units (ICUs) is disconcertingly low.

AIM

To identify the effective intervention(s) for increasing HH compliance among HCWs in adult ICUs.

METHODS

Two major electronic databases, OVID Medline and CINAHL, were searched by using a combination of MeSH terms and text words (e.g. hand hygiene, hand washing, compliance, adher*, improve*, develop* and intensive care unit) for relevant articles. This was supplemented by Google Scholar and hand searching of included bibliographies. Data from identified articles were then abstracted, quality-assessed, and combined into a summary effect.

FINDINGS

Of 89 titles and abstracts that were identified, 14 articles were finally included. Overall study quality was good. However, variations in design, setting, sample size, and intervention(s) tested precluded a meta-analysis; hence a narrative synthesis was conducted. The interventions included education, observation, provision of supplies, improving access and directive support; tested singly or in combination; resulted in positive outcomes in all but one study. A combination of administrative support, 'supplies', education and training, reminders, surveillance, and performance feedback raised the compliance from a baseline of 51.5% to a record 80.1%; but no set of intervention(s) could improve the compliance to the desired near-100% level.

CONCLUSION

Available data suggest that multi-modal interventions are effective in raising the compliance to a 'plateau' level but not up to the desired standard. Methodologically appropriate trials of combined interventions could enhance the evidence about interventions to improve hand hygiene compliance among ICU staff.

Knowledge, Attitude, and Practice of Use of Safety Precautions Among Health Care Workers in a Nigerian Tertiary Hospital, 1 Year After the Ebola Virus Disease Epidemic

BACKGROUND

Several studies have found that compliance with universal precautions (UP) reduces the risk of exposure to diseases transmitted through blood and body fluids. Several efforts were made during the 2014 Ebola virus disease (EVD) outbreak in Nigeria to ensure a better behavioral change toward the practice of UP.

OBJECTIVES

This study assessed knowledge, attitude, and practice of the use of universal safety precautions among health care workers in a tertiary hospital in Osun State in southwestern Nigeria, 1 year after the containment of the EVD epidemic in Nigeria.

METHODS

Descriptive cross-sectional study among 274 health care workers of LAUTECH Teaching Hospital Osogbo, selected using systematic sampling method. Data collected using semistructured, pretested questionnaires were analyzed using SPSS software version 17.0 (Chicago, IL, SPSS Inc.).

FINDINGS

Two hundred twenty (80.3%) washed their hands regularly after procedures, 256 (93.4%) used gloves regularly when caring for all patients, 100 (36.5%) said they occasionally recap needles carefully, and 250 (91.2%) said they properly handled and disposed sharp instruments and wastes. About 224 (81.8%) had good mean knowledge score, 154 (56.2%) had a positive attitude score, and 192 (70.1%) had a good mean practice score for UP among respondents. The practice of UP was statistically significantly associated with gender, years of work experience (P = .002), and knowledge of (P = .039) and attitude about UP (P = .007).

CONCLUSIONS

The good knowledge and practice scores of UP were associated with better attitude toward handwashing and the use of gloves during the post-EVD period compared with the pre-EVD period. A significant proportion still recap used needles just like during the pre-EVD period.

A Survey of Nurses' Compliance with Hand Hygiene Guidelines in Caring for Patients with Cancer in a Selected Center of Isfahan, Iran, in 2016

Background

Hand hygiene is one of the key ways of preventing healthcare-associated infections (HCAI), especially in patients with cancer. The aim of this study was to determine nurses' compliance with hand hygiene guidelines in caring for patients with cancer in a selected center in Isfahan, Iran, in 2016.

Materials and Methods

The present observational study was conducted on nurses in a cancer center in Isfahan in 2016. The participants were selected via convenience sampling method. Nurses serving at bedsides and willing to participate were entered into the study. Data were collected through the direct observation of nurses during delivering routine care, using the standard checklist for direct observation of the "five moments for hand hygiene" approach.

Results

In the present study, 94 nurses were studied at 500 clinical moments. The overall hand hygiene compliance rate was 12.80%. The highest hand hygiene compliance rate was observed in the after body fluid exposure moment (72.70%). In addition, hand hygiene compliance rate in preprocedure indications (before patient contact and before aseptic procedure) and postprocedure indications (after patient contact, after body fluid exposure, and after patient surrounding contact) were 3.40 and 21%, respectively, which had a significant correlation (p = 0.001).

Conclusions

The findings indicate that the hand hygiene compliance rate among nurses was low. Further research in this regard is recommended in order to find the causes of low compliance with hand hygiene and design interventions for improvement in hand hygiene compliance rate among nurses.

Feasibility of a real-time hand hygiene notification machine learning system in outpatient clinics

BACKGROUND

Various technologies have been developed to improve hand hygiene (HH) compliance in inpatient settings; however, little is known about the feasibility of machine learning technology for this purpose in outpatient clinics.

AIM

To assess the effectiveness, user experiences, and costs of implementing a real-time HH notification machine learning system in outpatient clinics.

METHODS

In our mixed methods study, a multi-disciplinary team co-created an infrared guided sensor system to automatically notify clinicians to perform HH just before first patient contact. Notification technology effects were measured by comparing HH compliance at baseline (without notifications) with real-time auditory notifications that continued till HH was performed (intervention I) or notifications lasting 15 s (intervention II). User experiences were collected during daily briefings and semi-structured interviews. Costs of implementation of the system were calculated and compared to the current observational auditing programme.

FINDINGS

Average baseline HH performance before first patient contact was 53.8%. With real-time auditory notifications that continued till HH was performed, overall HH performance increased to 100% (P < 0.001). With auditory notifications of a maximum duration of 15 s, HH performance was 80.4% (P < 0.001). Users emphasized the relevance of real-time notification and contributed to technical feasibility improvements that were implemented in the prototype. Annual running costs for the machine learning system were estimated to be 46% lower than the observational auditing programme.

CONCLUSION

Machine learning technology that enables real-time HH notification provides a promising cost-effective approach to both improving and monitoring HH, and deserves further development in outpatient settings.

Reducing health care-associated infections by implementing separated environmental cleaning management measures by using disposable wipes of four colors

Background

Environmental cleaning is a fundamental principle of infection control in health care settings. We determined whether implementing separated environmental cleaning management measures in MICU reduced the density of HAI.

Methods

We performed a 4-month prospective cohort intervention study between August and December 2013, at the MICU of Cathay General hospital. We arranged a training program for all the cleaning staff regarding separated environmental cleaning management measures by using disposable wipes of four colors to clean the patients' bedside areas, areas at a high risk of contamination, paperwork areas, and public areas. Fifteen high-touch surfaces were selected for cleanliness evaluation by using the adenosine triphosphate (ATP) bioluminescence test. Then data regarding HAI densities in the MICU were collected during the baseline, intervention, and late periods.

Results

A total of 120 ATP readings were obtained. The total number of clean high-touch surfaces increased from 13% to 53%, whereas that of unclean high-touch surface decreased from 47% to 20%. The densities of HAI were 14.32‰ and 14.90‰ during the baseline and intervention periods, respectively. The HAI density did not decrease after the intervention period, but it decreased to 9.07‰ during the late period.

Conclusion

Implementing separated environmental cleaning management measures by using disposable wipes of four colors effectively improves cleanliness in MICU environments. However, no decrease in HAI density was observed within the study period. Considering that achieving high levels of hand-hygiene adherence is difficult, improving environmental cleaning is a crucial adjunctive measure for reducing the incidence of HAIs.

Infection Prevention Strategy in Hospitals in the Era of Community-Associated Methicillin-Resistant Staphylococcus aureus in the Asia-Pacific Region: A Review

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as an important cause of healthcare-associated infection. CA-MRSA clones have replaced classic hospital MRSA clones in many countries and have shown higher potential in transmission and virulence than hospital MRSA clones. In particular, the emergence of CA-MRSA in the Asia-Pacific region is concerning owing to insufficient infection control measures in the region. The old strategies for infection prevention and control of MRSA comprised adherence to standard precaution and policy of active screening of MRSA carriers and decolonization, and it has been controversial which strategy is better in terms of outcome and cost-effectiveness. Epidemiological changes in MRSA has made the development of infection prevention strategy more complicated. Based on the literature review and the questionnaire survey, we considered infection prevention strategies for healthcare settings in the Asia-Pacific region in the era of CA-MRSA.

Interventions to improve hand hygiene compliance in patient care

BACKGROUND

Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure. This is an update of a previously published review.

OBJECTIVES

To assess the short- and long-term success of strategies to improve compliance to recommendations for hand hygiene, and to determine whether an increase in hand hygiene compliance can reduce rates of health care-associated infection.

SEARCH METHODS

We conducted electronic searches of the Cochrane Register of Controlled Trials, PubMed, Embase, and CINAHL. We conducted the searches from November 2009 to October 2016.

SELECTION CRITERIA

We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series analyses (ITS) that evaluated any intervention to improve compliance with hand hygiene using soap and water or alcohol-based hand rub (ABHR), or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened citations for inclusion, extracted data, and assessed risks of bias for each included study. Meta-analysis was not possible, as there was substantial heterogeneity across studies. We assessed the certainty of evidence using the GRADE approach and present the results narratively in a 'Summary of findings' table.

MAIN RESULTS

This review includes 26 studies: 14 randomised trials, two non-randomised trials and 10 ITS studies. Most studies were conducted in hospitals or long-term care facilities in different countries, and collected data from a variety of healthcare workers. Fourteen studies assessed the success of different combinations of strategies recommended by the World Health Organization (WHO) to improve hand hygiene compliance. Strategies consisted of the following: increasing the availability of ABHR, different types of education for staff, reminders (written and verbal), different types of performance feedback, administrative support, and staff involvement. Six studies assessed different types of performance feedback, two studies evaluated education, three studies evaluated cues such as signs or scent, and one study assessed placement of ABHR. Observed hand hygiene compliance was measured in all but three studies which reported product usage. Eight studies also reported either infection or colonisation rates. All studies had two or more sources of high or unclear risks of bias, most often associated with blinding or independence of the intervention.Multimodal interventions that include some but not all strategies recommended in the WHO guidelines may slightly improve hand hygiene compliance (five studies; 56 centres) and may slightly reduce infection rates (three studies; 34 centres), low certainty of evidence for both outcomes.Multimodal interventions that include all strategies recommended in the WHO guidelines may slightly reduce colonisation rates (one study; 167 centres; low certainty of evidence). It is unclear whether the intervention improves hand hygiene compliance (five studies; 184 centres) or reduces infection (two studies; 16 centres) because the certainty of this evidence is very low.Multimodal interventions that contain all strategies recommended in the WHO guidelines plus additional strategies may slightly improve hand hygiene compliance (six studies; 15 centres; low certainty of evidence). It is unclear whether this intervention reduces infection rates (one study; one centre; very low certainty of evidence).Performance feedback may improve hand hygiene compliance (six studies; 21 centres; low certainty of evidence). This intervention probably slightly reduces infection (one study; one centre) and colonisation rates (one study; one centre) based on moderate certainty of evidence.Education may improve hand hygiene compliance (two studies; two centres), low certainty of evidence.Cues such as signs or scent may slightly improve hand hygiene compliance (three studies; three centres), low certainty of evidence.Placement of ABHR close to point of use probably slightly improves hand hygiene compliance (one study; one centre), moderate certainty of evidence.

AUTHORS' CONCLUSIONS

With the identified variability in certainty of evidence, interventions, and methods, there remains an urgent need to undertake methodologically robust research to explore the effectiveness of multimodal versus simpler interventions to increase hand hygiene compliance, and to identify which components of multimodal interventions or combinations of strategies are most effective in a particular context.

A nationwide covert observation study using a novel method for hand hygiene compliance in health care

BACKGROUND

Evaluation and feedback is a core hand hygiene (HH) improvement strategy. The covert observation method avoids observation bias inherent to the overt method. The aim of the study was to observe HH compliance by a novel covert method in a real-world setting.

METHODS

We conducted a 2-year, nationwide, prospective, observational study in teaching hospitals across Taiwan. Medical students and students who may have contact with patients in their careers were recruited as participants. A novel, shorthand notation method for covert observation was used. Observation results were reported through a study website.

RESULTS

There were a total of 25,379 HH opportunities covertly observed by 93 observers. Overall HH compliance was 32.0%. Health care workers had the highest HH compliance for indication 4 (42.6%), and the lowest for indication 5 (21.7%). Overall handrubbing percentage was high, reaching 83.6%. The HH compliance increased significantly with an increase in the number of indications within 1 HH opportunity (P < .001).

CONCLUSIONS

The overall HH compliance by the covert observation method was low. An innovative shorthand notation method facilitated covert observation, and website reporting was demonstrated to be feasible for large-scale observation.

Use of ventilator utilization ratio for stratifying alcohol-based hand-rub consumption data to improve surveillance on intensive care units

BACKGROUND

Germany has established a nationwide surveillance system of alcohol-based hand-rub consumption (AHC) per patient-day in hospital settings as a surrogate parameter for hand hygiene (HH) compliance. Analysis of AHC data in intensive care units (ICUs) shows not only a wide range of consumption between units of different specialties, but also within units of one specialty. This seems to reflect variation in the number of HH opportunities per patient-day between ICUs due to variation in complexity of care.

AIM

To investigate whether ventilator utilization ratio (VUR) might be a good surrogate for describing complexity and intensity of care on ICUs and whether stratification by VUR works as a new method of setting benchmarks for AHC data.

METHODS

Data from 365 ICUs participating in the German national nosocomial infection surveillance system (KISS) were used. VUR was calculated by dividing the number of ventilator-days per unit by the number of patient-days per unit. AHC was stratified according to VUR in quartiles.

FINDINGS

The median AHC was 107mL/patient-day [interquartile range (IQR): 86-134] and the median VUR was 33% (IQR: 22-45%). The Spearman rank correlation coefficient was 0.28 (P<0.0001). After stratifying AHC according to VUR, the AHC in quartile I was significantly lower compared to quartile IV. There was also significant difference between quartile I and quartiles II and III.

CONCLUSION

Stratification of AHC data according to VUR is suggested to improve the quality of benchmark parameters based on AHC data as surrogate parameter for HH compliance in ICUs.